Dressing and Bandaging

Introduction

The skin is the first line of defense, a protective underlying structure from invasion by microorganisms of the body. Intact skin protects the person from chemical and mechanical injury. Skin has two layers; epidermis and dermis. When the skin is injured, the epidermis functions to resurface the wound and restore the barrier against invading organisms while the dermis responds to restore the structural integrity and the physical properties of the skin. The nurse plays a major role in maintaining the patient's skin integrity, in identifying risk factors that predispose a patient to a break in integrity, in intervening to prevent or reduce a patient's risk for impaired skin integrity, and providing specific wound care when breaks in integrity arise.

Wounds

A wound is a break or disruption in the normal integrity of the skin and tissue. Causes of injury may be the result of mechanical, chemical, electrical, thermal, or nuclear sources. Many wounds are superficial requiring local first aid including cleansing and dressing. Some wounds are deeper and need medical attention to prevent infection and loss of function, due to damage to underlying structures like bone, muscle, tendon, arteries and nerves.

Types of Wound

Wounds are classified according to the extent of injury, the causes, the type of wounds and presence or absence of pathogens.

Open Wound and Closed Wound

Open Wound: Open wound is one in which there is a cut or break in the continuity of skin or mucus membranes. In opened wound skin is broken which allows blood to escape from the body and providing a portal of entry for microorganisms. Open wounds can be classified according to the object that caused the wound.

Types of Open Wound

Incisions or Incised Wounds: Caused by a clean, sharp-edged object such as a knife, a razor or a glass splint.

Lacerations: Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue.

Abrasions (grazes): Superficial wounds in which the topmost layer of the skin (the epidermis) is scraped off due to friction. Abrasions are often caused by a sliding fall onto a rough surface.

Puncture Wounds: A puncture wound is produced by a sharp pointed object piercing the deep tissues; intentional such as venipuncture or accidental, leaving a very small opening on the surface.

Penetration Wounds: Foreign object entering the skin or mucous membrane and lodges in underlying tissue such as a knife entering and coming out from the skin.

Gunshot Wounds: Caused by a bullet or similar projectile driving into or through the body. There may be two wounds, one at the site of entry and one at the site of exit, generally referred to as a "through and through."

Closed Wound: A close wound results from a blow, force or strain cause by trauma such as fall, an assault or a motor vehicle accident. The skin is not broken but soft tissue is damaged and internal injury and hemorrhage may occur e. g. contusion or bruises and hematomas.

Types of Closed Wound

Contusions: More commonly known as bruises, caused by a blunt force trauma that damage tissue under the skin. Underling skin is remains intact.

Hematomas: Also called a blood tumor, caused by damage to a blood vessel that in turn causes blood to collect under the skin.

Crush injury: Caused by a great or extreme amount of force applied over a long period of time.

Acute and Chronic Wound

Acute or traumatic wounds are the result of injuries that disrupt the tissue. These wounds such as surgical incisions usually heal within days to weeks. Wound edges are well approximated & damp; the risk of infection is lessened.

Close wounds do not progress through normal sequence of repair. The healing process is impended. Wound edges are often not approximated, the risk of infection is increased, and the normal healing time is delayed. Chronic wounds include pressure, venous, and diabetic ulcers. Typically, an insufficiency in the circulation or other systemic support of the tissue causes it to fail and disintegrate skin.

Surgical and Traumatic Wound

A surgical wound is an intentional type of wound, usually performed by the surgeons during the surgical procedures under aseptic precautions. They are usually called incisions.

A traumatic wound is an unexpected wound usually caused by accidents. They occur in septic conditions.

Clean, Contaminated and Infected Wound

A clean wound: It contains no pathogenic micro-organisms. A surgical wound is considered to be a clean wound because it is made under aseptic conditions. 

A contaminated wound: It is one in which there is a great likelihood of pathogenic micro- organisms invading the wound. A wound may become contaminated by the foreign bodies that have entered through the injured surfaces during the injury.

An infected wound: It is one in which pathogens have invaded and overcome the body's first line of defense, producing clinical signs of infection. The infected wound is also called 'septic wound'.

Intentional Wounds and Unintentional Wound

An intentional wound is the result of planned invasive therapy or treatment. These wounds are purposefully created for therapeutic purposes. Examples of intentional wounds include those that result from surgery, intravenous therapy, and lumbar puncture.

Unintentional wounds are accidental from unexpected trauma, such as from accidents, injury & burns. Because the wounds occur in an unsterile environment, contamination is likely.

Wound Healing

Wound healing is a process of tissue response to injury. Wound healing is a complex biological process that consists of hemostasis, inflammation, proliferation, and remodeling. Large numbers of cell types-including neutrophils, macrophages, lymphocytes, keratinocytes, fibroblasts, and endothelial cells-are involved in this process. Injured tissues are repaired by physiologic mechanisms that regenerate functioning cells and replace connective tissue cells with scar tissue. Normally, the healing process occurs without assistance. However, interventions can help to support the process.

Wound repair occurs by primary intention, secondary intention and tertiary intention depending on the wound type and cause. The healing process is essentially the same, although the timescales may differ.

Primary Intention: Wounds healed by primary intention are well approximated. Acute wounds for example, those caused by surgery where there is minimal tissue loss, healed by primary intention.

Secondary Intention: The wounds where there is considerable tissue loss, require more tissue replacement and often contaminated for example, large open wounds and pressure ulcers, healing occurs through secondary intention by the process of granulation and epithelization. Wounds healed by secondary intention have edges that are not well approximated. If a wound that is healing by primary intention becomes infected, it will be healed by secondary intention. Wounds that are healed by secondary intention take longer to heal and form more scar tissue.

Tertiary Intention: Wounds healed by tertiary intention are those wounds left open for several days to allow edema or infection to resolve or exudate to drain, then closed. Wound surfaces start to granulate and scaring is common.

Wound Healing Process

There are basically 4 phases to the healing process:

Hemostasis: Hemostasis, the first phase of healing, begins at the onset of injury, with vascular constriction and fibrin clot formation. It is the instinctive response for the body to stop bleeding and loss of blood, where platelets play a role by aggregating, as well as by releasing cytokines, chemokine and hormones. This involves coagulation, blood changing from a liquid to a gel. Hemostasis has three major steps: vasoconstriction, temporary blockage of a break by a platelet plug, and blood coagulation, or formation of a fibrin clot. Vasoconstriction occurs to limit blood loss under the effects of vasoactive mediators (epinephrine, norepinephrine, prostaglandins, serotonin, and thromboxane), causing temporary blanching of the wound. Platelets adhere to the site of injury, become activated and aggregate with fibrinogen into a soft plug that limits blood loss, a process termed primary hemostasis. Proteins and small molecules are released from granules by activated platelets, stimulating the plug formation process. Fibrinogen from plasma forms bridges between activated platelets. These events initiate the clotting cascade (secondary hemostasis).

Inflammatory Phase: The inflammatory phase is the body's natural response to injury. to Defensive/Inflammatory Phase focuses on destroying bacteria and removing debris essentially preparing the wound bed for the growth of new tissue. Once haemostasis has been achieved, blood vessels then dilate due to histamine, prostaglandins, kinins, and leukotrienes, to allow essential cells; antibodies, white blood cells, growth factors, enzymes and nutrients to reach the wounded area and capabillary permeability increases, allowing plasma and blood components to leak out into the area that is injured, forming a liquid called exudate. White blood cells, predominately leucocytes and macrophages, move to the wound. Leukocytes arrive first to ingest bacteria and cellular debris. About 24 hours after the injury, macrophages enter the wound area and remain for an extended period. These are essential to the healing process. They not only ingest debris, but also release growth factors that are necessary for the growth of epithelial cells and new blood vessels. These growth factors also attract fibroblasts that help to fill in the wound which is necessary for the next stage of healing? This phase often lasts 4 to 6 days and is often associated with edema, mildly elevated temperature, redness, pain leukocytosis and generalizes malaise.

Proliferative Phase: During proliferation, the wound is rebuilt with new granulation tissue which is comprised of collagen and extracellular matrix and into which a new network of blood vessels develop, a process known as angiogenesis. Blood vessels will supply the rebuilding cells with oxygen and nutrients to sustain the growth of the new cells and support the production of proteins primarily collagen. The collagen acts as the framework upon which the new tissues build. Collagen is the dominant substance in the final scar. The Proliferative phase features 3 distinct stages: 1) filling the wound; 2) contraction of the wound margins; and 3) covering the wound (epithelialization). During the first stage, shiny, deep red granulation tissue fills the wound bed with connective tissue, and new blood vessels are formed. During contraction, the wound margins contract and pull toward the center of the wound. In the third stage, epithelial cells arise from the wound bed or margins and begin to migrate across the wound bed in leapfrog fashion until the wound is covered finally resurface the wound, a process known as 'epithelialisation'. Its formation occurs 3-5 days following injury and overlaps with the preceding inflammatory phase and last for 4 to 24 days. Healthy granulation tissue is dependent upon the fibroblast receiving sufficient levels of oxygen and nutrients supplied by the blood vessels. The colour and condition of the granulation tissue is often an indicator of how the wound is healing. Healthy granulation tissue is granular and uneven in texture; it does not bleed easily and is pink / red in colour. Dark granulation tissue can be indicative of poor perfusion, ischemia and / or infection.

Maturation Phase: During the maturation phase, the new tissue slowly gains strength and flexibility. Cellular activity reduces and the number of blood vessels in the wounded area regress and decrease. Here, collagen fibers reorganize, the tissue remodels and matures and there is an overall increase in tensile strength. The maturation phase varies greatly from wound to wound, often lasting anywhere from 21 days to 2 years.

Factors Affecting Wound Healing

Multiple factors can cause impaired wound healing by affecting one or more phases of the process and are categorized into local and systemic factors. Local factors are those that directly influence the characteristics of the wound itself, while systemic factors are the overall health or disease state of the individual that affect his or her ability to heal.

Wound Type: Depending on whether the wound is the result of surgery or an injury (chronic wounds), patients may experience different problems during the recovery time.

Dry Skin: Patients who are prone to dry skin, especially the elderly are at risk for skin lesions, excoriations, infection, and thickening due to scratching and rubbing the skin. This leads to difficulty for the skin to heal adequately.

Wound Infection: Due to the injury process wounds may be contaminated with bacteria. However, the patient's immune competence and the size of the bacterial inoculum determine whether the wound will become infected. If the patient has normal host defenses the wound will heal effectively.

Hygiene: Personal hygiene of both the patient and anyone else who is in contact with the wound could have an effect on the healing process.

Oxygenation: When the patient lacks the proper amount of oxygen in the bloodstream, the patient will endure vasoconstriction. This may be the result of low blood volume, unrelieved pain or hypothermia. Smoking also leads to tissue hypoxia.

Infections: Once skin is injured, micro-organisms that are normally sequestered at the skin surface obtain access to the underlying tissues.

Presence of Debris, Necrotic Tissue, and Infection: Tissue necrosis occurs from radiation treatments which may increase the risk of local or systemic ischemia

Repeated Trauma: The defense mechanisms of the patient's body become limited due to overuse if the patient has multiple wounds or surgeries.

Systemic Causes: Common systemic disorders include diabetes mellitus, malnourishment, and immunodeficiency affect wound healing. There are medications and other diseases that compromise the healing of wounds and many of the medications such as prolonged steroid use leads to thinning skin.

Age: Everything slows down during the aging process, including the phases of wound healing. Aging causes many changes that adversely affect the skin and its ability to heal and regenerate itself.

Sex Hormones: Sex hormones play a role in age-related wound-healing deficits. Compared with aged females, aged males have been shown to have delayed healing of acute wounds. Female estrogens, male androgens and their steroid precursor dehydroepiandrosterone appear to have significant effects on the wound-healing process mined at brow it wor

Stress: Stress has a great impact on human health and social behavior. Psychological stress causes a substantial delay in wound healing.

Diabetes: Diabetes affects hundreds of millions of people worldwide. Diabetic individuals exhibit a documented impairment in the healing of acute wounds.

Medications: Many medications, such as those which interfere with clot formation or platelet function, or inflammatory responses and cell proliferation have the capacity to affect wound healing.

Obesity: Obese individuals frequently face wound complications, including skin wound infection, dehiscence, hematoma and seroma formation, pressure ulcers, and venous ulcers. The increase in pressure ulcers or pressure-related injuries in obese individuals is also influenced by hypovascularity, since poor perfusion makes tissue more susceptible to this type of injury. (Wilson and Clark, 2004; Anaya and Dellinger, 2006; Greco et al., 2008).

Alcohol Consumption: Clinical evidence and animal experiments have shown that exposure to alcohol impairs wound healing and increases the incidence of infection. Alcohol exposure diminishes host resistance, and ethanol intoxication at the time of injury is a risk factor for increased susceptibility to infection in the wound (Choudhry and Chaudry, 2006). Acute ethanol exposure can lead to impaired wound healing by impairing the early inflammatory response, inhibiting wound closure, angiogenesis, and collagen production, and altering the protease balance at the wound site.

Smoking: Nicotine interferes with oxygen supply by inducing tissue ischemia, since nicotine can cause decreased tissue blood flow via vasocontructive effects (Ahn et al., 2008; Sørensen et al., 2009). Nicotine stimulates sympathetic nervous activity, resulting in the release of epinephrine, which causes peripheral vasoconstriction and decreased tissue blood perfusion. Nicotine also increases blood viscosity caused by decreasing fibrinolytic activity and augmentation of platelet adhesiveness.

Nutrition: Nutrition has been recognized as a very important factor that affects wound healing. The wound is unable to heal properly if the patient lacks the necessary nutrients to maintain adequate energy for collagen synthesis.

Complications of Wound Healing

There are various complications during the process of wound healing. Impaired wound healing requires observation and ongoing interventions. One must be able to recognize the seriousness of the signs and symptoms that can arise before complications which can turn vital.

Haemorrhage

• Bleeding may indicate a dislodged clot, slipped sutures, coagulation problems, and trauma to blood vessels or tissues.
• This type of bleeding could show up on the wounds dressing
• Internal hemorrhaging can occur inside the cavity of the body while the dressing stays dry and shows no signs of collecting blood.

Dehiscence

• This is the medical term for when the wound layers separate.
• Most people may experience this after coughing, sneezing or vomiting.
• Immediately place a sterile dressing over the area until a physician can evaluate the area.

Evisceration

• It is a medical emergency.
• This happens when the abdominal organs protrude through the opening of an incision.
• The wound contents are to be covered in warm, sterile saline dressings.
• This type of complication will require surgical repair.

Wound infection

• Infection is most common form of complication of wound healing. A wound is "infected" when it contains purulent drainage.
• The client may display fever, tenderness or pain at the site of the wound, edema and an elevated WBC.
• Purulent drainage will have an odour and depending on the pathogen causing the infection it can be green or yellow in color. 

Pain: Recurrence of pain at the site of injury should be interpreted as a sign of inflammation and infection.

Abscess Formation: It is a localized collection of pus which complicates the healing process by enlarging the dead space which must be filled in.

Cellulitis: If the inflammation is localized, but extends to the surrounding cells with an edematous appearance of the parts it is called cellulitis.

Necrosis or Gangrene: If the blood supply is not restored to the area, the death of the tissues may take place. It is called gangrene.

Keloids: These are huge ugly, tumour like over growths of scar tissues seen in certain individuals.

Contractures: Disability and severe deformity occurs when severe injuries are located over a joint and are healed by secondary union.

Fistula Formation: A fistula is an abnormal passage from an internal organ to the outside of the body or from one internal organ to another. Fistula formation is often the result of infection that has developed into an abscess, which is a collection of infected fluid that has not drained. Accumulated fluid applies pressure to surrounding tissues, leading to the formation of the unnatural passage.

Dressing

Dressing is a process of cleaning a wound and applying a sterile dressing with or without medicine. It is process of cleaning a wound using aseptic technique for the purposes of promoting healing and preventing infections. The dressing technique varies, depending on the goal of the treatment plan for the wound.

Types

Dressings vary by type of material and mode of application. They need to be easy to apply, comfortable, and made of materials that promote wound healing.

• Medical dressing: Medical dressing is done for close wound e.g. application of magnesium sulphate paste on the abscess. It does not require sterile technique.
• Surgical dressing: It requires all the equipment to be sterilized by an aseptic technique because the wound is open and the chance of infection is more.
• Open dressing: The wound is left open to the air without gauze dressing. The cream is reapplied as needed.
• Closed dressing: In closed method, gauze dressing is impregnated with antimicrobial cream and applied to the wound.
• Supportive: Supportive is light dressing.
• Pressure dressing: Pressure dressing is a thick sterile pad made of gauze applied with a firm bandage or tape or binder which is used for where there is danger of bleeding and discomfort.
• Medicated and unmediated
• Dry and wet dressing

Purposes

• To protect the wound from mechanical injuries and contamination with micro-organisms.
• To remove soiled dressing to prevent spread of infection.
• To observe the nature of wound for information.
• To aid in hemostasis by applying pressure.
• To inhabit or kill organisms by using dressing that contains antiseptic solutions.
• To promote healing by absorbing drainage and debriding a wound.
• To promote wound granulation and healing.
• To support or splint the wound site.
• To apply a sterile protective tissue covering.
• To minimize accumulation of fluid by applying pressure dressing.
• To immobilize the part or provide rest to the
• To apply medication for healing of wounds.
• To restore the function of the part.
• To promote physical, psychological and aesthetic comfort.
• To promote thermal insulation to the wound surface.
• To prevent contamination from bodily discharges e.g. feces, urine.

Principles

• A dressing on a wound that was draining needed to be changed frequently to stop microbial growth and skin deterioration.
• Under the dressing, in the dark, warm, and damp environment, bacteria multiply quickly.
• Reduce the usage of tape and keep the skin dry and clean to reduce peri-wound skin deterioration.
• If the wound is healing as a result of secondary intention, a dressing must support a moist wound environment.
• The progress of epithelialization is aided by a moist wound foundation, allowing the wound to resurface as soon as feasible.
• While changing the dressing, inspecting, and closing the wound, adhere to strict aseptic technique.
• Everything that touches a wound needs to be sterilized.
• To prevent cross infection, hands should be properly cleansed both before and after applying each dressing.
• Disinfecting all items will ensure that they are clean and pathogen-free.
• For large dressings, put on a gown, sterile gloves, and a mask.
• Cleanse a wound from the area that is least contaminated to the area that is most contaminated.
• In order to avoid mea timed, dressing is changed at least 15 minutes after the room has been cleaned.
• Turn the fan off.
• When the wound is open, refrain from talking, sneezing, and coughing.
• To ease the patient's concern, keep the soiled side of the dressing out of sight.
• To clean the wound, use a single stroke.

Articles

• A sterile set containing:
  • Small bowl
  • Artery forceps
  • Dissecting forceps
  • Scissor
  • Kidney tray
  • Cotton/gauze /cotton pads
  • Antiseptic solution /cleansing solution
  • Gloves
• Adhesive tape
  • Scissors
• Bandage
• Plastic bag or bucket
• Rubber sheet
• Prescribed medicine/ointment/powder
• Screen

Procedure